Opinion: From here to JUPITER

3rd April 2009

319

Dr Erica Spatz tells how a new analysis estimated the number of older American adults who may benefit from statin therapy following the JUPITER trial results.

“Primary prevention strategies for cardiovascular disease have the potential to impact a sizeable portion of the population. Thus, when findings from the JUPITER (Justification for the use of statins in primary prevention: an intervention trial evaluating rosuvastatin) revealed that older adults without known cardiovascular disease, at-goal low-density lipoprotein cholesterol (LDL-C), and elevated levels of high sensitivity C-reactive protein (hsCRP) had decreased cardiovascular events when treated with rosuvastatin as compared to placebo, many questions arose about its adoption into clinical practice.

Current guidelines for statin use focus on patients with elevated LDL-C levels. However, if recommendations for statin therapy are to be expanded beyond those with high cholesterol levels, a critical next step is to understand the size and clinical characteristics of the population potentially impacted.

Our group sought to estimate the size of and describe this new population for whom statin therapy may now be recommended based on JUPITER’s findings. Using data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative probability sample of the community-residing population in the USA, we replicated the JUPITER study population, limiting our analysis to men 50 years and older and women 60 years and older. We then determined who among this group already qualified for statin therapy based upon the National Cholesterol Education Panel/Adult Treatment Panel (NCEP/ATP) III criteria. In the remaining group, we used LDL-C and hsCRP levels to determine eligibility for statin therapy based on JUPITER’s findings, specifically LDL-C <130mg/dL and hsCRP >2mg/L. We then compared the demographic and clinical characteristics of individuals in the three groups stratified by statin eligibility: NCEP/ATPIII-indicated group, JUPITER-indicated group, and those who remained without any indication for statin therapy.

The results were striking. Approximately 58% of the middle-aged to older adult population had an indication for statin therapy based upon NCEP/ATPIII criteria, though less than half of this group was actually receiving treatment. An additional 19.2% of the population would qualify for statins based on JUPITER’s findings, including 8.1 million with an LDL-C <130mg/dL and hsCRP >2mg/L, and an additional 3.1 million individuals with LDL-C between 130-160mg/dL and hsCRP >2mg/L, a group for whom JUPITER’s recommendations might reasonably be extended. Thus, almost 80% of the older adult population may now qualify for statin therapy.

A second aim of our study was to determine whether the JUPITER-indicated group could be distinguished from those with low hsCRP and no indication for statin therapy and from those who qualify for statin therapy based on current NCEP/ATPIII criteria. We found that compared to those who would continue to have no indication for statin therapy, the JUPITER-indicated group was more likely to be older, female, obese, have hypertension and the metabolic syndrome. In contrast, JUPITER-indicated subjects shared several characteristics with the NCEP/ATPIII-indicated group, including sociodemographic characteristics, smoking, abdominal obesity, and hypertension. These findings may help us in guiding future screening efforts that target populations more likely to have elevated hsCRP levels, and thus an increased risk for cardiovascular disease.

In summary, targeting elevated hsCRP levels for risk-reduction therapy has the potential to impact approximately 20% of the adult population of men aged >50 years and women aged >60 years who would otherwise not be recommended for a statin medication. Expanding recommendations for statin therapy will undoubtedly widen the evidence-practice gap, posing increasing challenges for health providers and systems already struggling to reach individuals with an NCEP/ATPIII recommendation for statin therapy. Additionally, it is unclear what is the most cost-effective strategy for identifying asymptomatic patients with elevated hsCRP levels. However, the JUPITER trial offers the opportunity to advance therapeutic strategies to prevent adverse cardiovascular outcomes.”

Dr Erica Spatz, internist, is a fellow at Robert Wood Johnson Clinical Scholar programme, Yale School of Medicine.